A cardiologist leaves her practice and joins another, after which a former patient of hers comes to the new practice for an appointment: Do you bill the visit as a new or established patient visit?
Many practices are puzzled by situations like this, says Terry Fletcher in her 2019 Coding Updates Virtual Boot Camp presentation “Non-Invasive and E/M Auditing for Cardiology” with ProfEdOnDemand. Determining the correct category for patient visits is a persistent challenge for coders, one you’ll need to master—along with all the 2019 cardiology CPT® code changes headed your way.
CPT v. CMS: Define ‘New’
Definitions of “new” patients versus “established” patients are less straightforward than they seem. The Centers for Medicare & Medicaid Services (CMS) and CPT® haven’t always lined up 100 percent on the issue, making it hard for you to know whose definition to follow.
Let’s take, for example, the CPT® definition of a new patient: “… one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” (Emphasis added.)
CMS’s definition as given in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.7A is very similar, except CMS omits “subspecialty.”
Rule of thumb: The mismatch in definitions can be confusing. Always use CPT® as a guide, but before submitting the claim, double-check specific payer rules.
Note: For information on billing for patients who first see a general clinical cardiologist followed by a cardiologist of a different subspecialty, Fletcher’s
2 Key Definition Elements
Although CMS and CPT® differ in that small way, their definitions do have two key phrases in common: “professional services” and “three years.”
Professional services include billable, face-to-face E/M services that can take place even after a physician has initially seen a patient. For example, if a physician sees a patient in the emergency room, then orders tests and asks the patient to return when the results are available, bill the subsequent visit as a new patient visit because it is the first time the physician is providing billable, face-to-face E/M services.
The second key element of this definition, “three years” refers to the fact that, to qualify as a new patient, the physician must not have seen the patient within the past three years.
Watch out: This calculation may seem simple, but some payers count the month of the last date of service, while others count the exact date.
Bill Smart: 2 Scenarios
When billing, you’ll probably come across scenarios like these:
Scenario 1: Going back to the scenario mentioned at the start of this post, here you would focus on the dates of service rather than where the physician is located. If the physician saw the patient on May 17, 2016 at her old practice and the second visit took place on July 13, 2018 at the new practice, then you would bill that second visit as an established patient visit—because less than thre years have passed.
Scenario 2: Dr. Jones sees a new patient on June 16, 2015. He suspects an issue and orders an electrocardiogram (EKG), but finds nothing unusual. No further services are offered, and this visit is billed as a new patient visit. The patient returns in June 2018 for billable, E/M services. Whether or not this visit is a new or established patient visit depends on the payer and the exact date of service. Check to see how specific the payer’s definition of three years is.
Solidify What You (Think You) Know
Untangling the scenarios to determine new v. established patient is a headache, but one you have to understand to face up not only to cardiology auditing, but also to payers. Since new patient codes have higher relative value units (RVUs), payers pay more attention to them and are quick to deny suspicious claims.
With a little extra training, says Fletcher, you’ll be ahead of other practices continuing to struggle with the nuances of new v. patient definitions and how to bill. The 2019 cardiology CPT® changes will have an impact on our cardiology practice, so get started now preparing for what’s to come.